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Percutaneous Emergency Airway Access

Key Points Clinicians should quickly recognize severe airway obstruction and hypoxia to allow fast intervention, which should include a rapid progression to emergency invasive airway access as opposed to multiple attempts to intubate the trachea. Proper identification of airway anatomy is the first step in successful performance of percutaneous invasive airway techniques and the avoidance of complications. The airway practitioner should always consider the danger of…

Rigid Bronchoscopy

Key Points Open communication between the surgeon and the anesthesiologist is of the highest importance during rigid bronchoscopy. Inspect the equipment before the procedure; ensure that the bronchoscopes, light sources, light carriers, and connectors are all in working order. Check that instruments (suction, graspers, telescopes) are the appropriate length for the selected bronchoscopes. Have a backup set that is a size smaller than what you plan…

Lung Isolation Techniques

Key Points Lung isolation should only be performed by well-trained and experienced practitioners who understand the significant risks and benefits of such techniques. Indications for lung isolation include protection of the healthy lung from contamination in the case of infection or hemorrhage; control of ventilation distribution; and bronchopulmonary lavage. Relative indications for lung separation are mainly for surgical exposure. Double-lumen tubes (DLTs) come in sizes 28,…

Combination Techniques

Key Points Combining airway techniques takes advantage of the respective strengths of each device while minimizing their specific shortcomings when used alone. The multimodal approach is appropriate in the use of various airway devices, including oxygenation tools. The multimodal approach is useful for teaching, clinical practice, and maintenance of knowledge in airway management. The most common examples of advantageous combinations in the field of airway management…

Flexible Scope Intubation Techniques

Key Points A proactive low threshold for FIS (Flexible Intubation Scopes) use is important when considering a DA. Rigid VAL, Optical Laryngoscopes, or stylet use when FISs are indicated can worsen already grim situations and impede FIS rescue. FIS instruments are frequently very delicate and expensive. However, balance FIS expenses against costs of multidevice airway rescue attempts; cardiac, airway, brain, psychological, and other system injuries; and…

Video-Assisted Laryngoscopy

Key Points The opportunity to take still pictures or video-record airway management stands to alter the approach to the medical record. For the novice practitioner or for patients predicted to be difficult to intubate by direct laryngoscopy (DL), video-assisted laryngoscopy (VAL) improves intubation success rates. When DL fails, VAL provides a high likelihood of success as a rescue technique. VAL may be as useful as a…

Nonvisual Techniques of Tracheal Intubation

Key Points Blind intubation techniques have proven to be effective, safe, and simple techniques, especially in a timely manner during emergency situations where fogging, presence of blood, secretions, and vomitus can create impossible conditions for the direct or indirect laryngoscopic visualization of the glottis or when alternative options are either unavailable or not functional. Successful nonvisual intubation depends largely on the clinician’s preparation, experience, and skill.…

Laryngoscopic Tracheal Intubation

Key Points “Resuscitation Sequenced Intubation” for managing critically ill patients and the physiologically difficult airway has become an accepted term describing the process of intubation and transition to positive-pressure ventilation that poses significant risk to the patient in an at-risk cohort. Just as less invasive airway management may be better suited for shockable rhythm cardiac arrests where early return of spontaneous circulation is more likely, there…

Supraglottic Airway Techniques

Key Points There is a wide range of supgraglottic airways (SGAs), and expertise with several devices is necessary to provide optimal airway management to patients in a wide range of settings. Although there is an expanding range of indications for use of SGAs, the safety profile for many of them remains undefined. Each practitioner must master the basic skills for optimal use before attempting more advanced…

Noninvasive Management of the Airway

Key Points The most important upper airway (UA) soft tissue obstruction site is the soft palate. The one-handed face-mask ventilation (FMV) technique airway maneuver is the chin-lift/head extension (CL/HE) maneuver applied in the sagittal plane (on the occipito-atlanto-axial joint). The two-handed airway maneuver is the jaw thrust applied in the transverse plane (on the temporomandibular joints). The chin elevation (by head extension or mandibular advancement) can…

History of Airway Management

“Everything has been said before, but since nobody listens, we have to keep going back and beginning all over again.” Andre Gidé, Le traité du Narcisse: Theorie du symbole, 1891 Key Points The early evolution of airway management techniques and equipment for anesthesia was largely driven by surgical need, the requirement for airway protection, and the treatment of infectious diseases, such as polio and diphtheria. The…

Techniques to Induce General Anesthesia

Key Points Neuromuscular blockade has been shown to improve the ability to face-mask ventilate and perform laryngoscopy. A ketamine induction is likely to preserve spontaneous ventilation; however, apnea has been reported, and airway obstruction is always possible. Succinylcholine, despite its side effects, is still recommended as the neuromuscular blocking drug of choice for rapid sequence induction and intubation (RSI) over rocuronium because of the advantages of…

Perioxygenation

Key Points The mainstay technique for increasing the apneic window is through preoxygenation with spontaneous face-mask ventilation and 100% oxygen. More recently, there has been increased emphasis on perioxygenation , which also involves providing oxygenation during the apneic period. Preoxygenation denitrogenates the lungs and creates an alveolar oxygen reservoir. The size of this reservoir can be increased by reducing dependent atelectasis through head-up patient positioning and…

Aspiration Prevention and Prophylaxis: Preoperative Considerations for the Full Stomach Patient

Key Points The incidence of pulmonary aspiration in the general surgical population is low, but it is slightly increased among obstetric, pediatric, and trauma patients. It remains the leading cause of death related to airway management. Regurgitation and aspiration can result from “light” anesthesia, coughing, or gagging in the patient whose airway is not protected with a cuffed endotracheal tube (ETT). Patients manifesting no evidence of…

Preparation of the Patient for Awake Intubation

KEY POINTS When faced with a difficult airway (DA), awake intubation is the gold standard for airway management. There are no absolute contraindications to awake intubation other than patient refusal, or a patient who is unable to cooperate (e.g., a child, a patient with an intellectual disability, or an intoxicated, combative patient). Preparation begins with a careful history and physical examination and a detailed discussion of…

Human Factors in Airway Management

Key Points Airway management occurs within the broad and complex sociotechnical system of healthcare delivery. Aspects of design, training, and team functioning can be modified to improve safety. Airway management is now a “team sport,” and interventions to improve safety should focus on team performance rather than individuals’ skills alone. Explicit communication involving the use of cognitive aids and other checklists should be used in all…

Algorithms for Management of the Difficult Airway

Key Points Adherence to the principles of an airway management algorithm and widespread adoption of such a structured plan should result in a reduction of respiratory catastrophes and a decrease in perioperative morbidity and mortality. Airway evaluation should consider any characteristics of the patient that could lead to difficulty in the performance of (1) face mask or supraglottic airway (SGA) ventilation, (2) direct or video-assisted laryngoscopy…

Development of an Airway Management Plan

“I have no intention of following the algorithm down to a surgical airway … can’t we just do a spinal?” Anonymous Resident Key Points Decision bias can be reduced by considering each aspect of airway management separately. The utility of any airway device is dependent on prior experience and availability; two different practitioners may justifiably come to widely opposing management decisions. The Cormack and Lehane (CL)…

Airway Assessment and Prediction of the Difficult Airway

KEY POINTS Poor airway assessment may contribute to poor patient outcomes. An airway history and physical examination should be performed in all patients undergoing airway management. Relevant diagnostic studies should be reviewed. No single test reliably predicts difficult mask ventilation (DMV), difficulty with a supraglottic airway (SGA), difficult laryngoscopy, or difficult intubation (DI). A greater number of airway abnormalities imply increasing difficulty. Proposed predictors of impossible…